POLICY AND PROCEDURE
Pain Management - Acute Pain
Issuing Department:
Nursing
Approved By:
Clinical Leadership Committee
I.
Reviewed By:
Sheryl Vugteveen, Clinical Leader, ICC/MSCC/MCC
Kathleen Lougheed, Clinical Leader, Family Birth Center
PURPOSE
All patients will receive the best level of pain control that can safely be provided in order to
prevent unrelieved pain.
II.
POLICY
Pain is recognized as a sixth vital sign. This policy provides guidelines to caregivers in how
to assess, treat, and assist in managing a patient’s pain.
III.
DEFINITIONS
A. “Pain is whatever the experiencing person says it is, existing whenever s/he says it
does” (McCaffery, 1968). Self-report is the preferred indicator of pain, and
behavioral/physiological indicators are used only when the patient is unable to selfreport, (i.e., vented patient newborn, infant, child- not sure if this adult only).
B. Maple Grove uses a self rating scale 0-10 to evaluate pain. 0 indicates no pain, 10
indicates worst pain imaginable.
C. Newborns, infants and children exhibit physiological and behavioral responses that are
similar to, but can be more intense than, adult responses (Merenstein).
D. Unrelieved, non-ischemic pain is defined as:
1. a pain scale intensity rating of equal to or greater than 4 or,
2. causes the patient distress or,
3. is unacceptable to the patient or,
4. limits the patient’s physical, cognitive or psychological function.
E. Cardiac pain needs to be assessed and treated immediately.
F. Pain relief is the alleviation of pain or a reduction in pain to a level of comfort that is
acceptable to the patient and is demonstrated by a decrease in the patient’s pain scale
rating and an improvement in physical, cognitive, behavioral, and/or psychosocial
functioning.
G. Opioid naive individual is defined as an individual who has NOT been utilizing an opioid
on a regular basis (e.g., four times per day) for an extended period of time (e.g., one
month).
H. Opioid tolerant individual is defined as an individual who has received an opioid on a
regular basis for an extended period of time.
I. Multi-model approach to pain management. This is defined as using pharmacological
(opioid and non-opioid) interventions and non-pharmacological interventions together to
provide comfort.
Maple Grove Hospital
Policy and Procedure
Pain Management – Acute Pain
Page 2 of 12
IV.
PROCEDURE: PAIN MANAGEMENT – ALL PATIENTS
A. Assess for presence of pain for all patients:
1. On initial assessment.
2. At regular intervals, with a minimum of t.i.d. (every 8 hour shift) and prn.
a. With each new report/rating of pain; before, during and after any known
pain-producing event.
b. With unrelieved pain.
c. Re-assess pain intensity after each pain management intervention
(pharmacological and non-pharmacological) once a sufficient time has
elapsed for the treatment to reach peak effect (within 2 hours of
intervention - general guidelines: 30 minutes for IV, 60 minutes for
PO/IM, and 15-60 minutes for non-pharmacological).
3. Assess patient's ability to use a pain rating scale and the patient's personal goal
for pain relief.
4. For newborn/infants/children - use age appropriate pain scale.
5. Pain rating scales used include: Numeric (0-10; 0 indicating no pain and 10
indicating worse possible pain), verbal, behavioral, faces, FLACC, and N-Pass
(see attached-need to attach if using).
6. Utilize the acronym "APP" (assume pain present) for patients who are unable to
self-report and/or are unable to demonstrate pain related behaviors. Examples of
patients this might affect include: the unresponsive patient, the sedated,
chemically paralyzed patient, potentially hospice patients and patients with brain
insults.
7. With initial assessment of pain and new onset of pain, assess factors utilizing
WILDA (W = in the patients own words, I = intensity (pain rating scale), L =
location, D = description, A = alleviating and aggravating factors), functional
status and quality of life.
8. Monitor for common side effects which may include oversedation, respiratory
depression, nausea/vomiting, pruritus and acute confusion.
B. Principles of Intervention/Patient Education
1. Provide patients/family with verbal and written information about pain
management.
2. Teach patients/families to use a pain rating scale that is age, condition, and
language appropriate for reporting pain intensity and that the goal of pain
management is prevention.
3. Teach patient/family pharmacologic and non-pharmacologic interventions.
4. Develop an individualized pain management plan which includes the patient’s
goal for pain management, patient preferences for treatment, age, type of pain,
risk for cognitive impairment, history of chemical dependency, chronic pain and
cultural beliefs and practices.
5. The physician should be notified of pain that remains at a 4 or greater or higher
than the patient's comfort level.
6. A guide to pharmacologic interventions with acute pain. See diagram below.
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Policy and Procedure
Pain Management – Acute Pain
Page 3 of 12
Moderate Pain
(e.g., 4-6 on 0-10 scale)
Low dose opioid
(e.g., Codeine, hydrocodone,
hydromorphone, methadone,
morphine, oxycodone)
+/-
Mild Pain
(e.g., 1-3 on 0-10 scale)
+/-
Non-opioid
(e.g., NSAID - if not
contraindicated for adults;
acetaminophen - pediatric
and adults >65 y.o.)
Severe Pain
(e.g., 7-10/10 on 0-10 scale)
+
High dose opioid
(e.g., Hydromorphone,
methadone, morphine,
oxycodone)
Adjuvant analgesic
(e.g., antidepressants: amitriptyline,
desipramine, nortriptyline;
anticonvulsants: gabapentin, Tegretol)
+/-
7. Choose IV or PO routes instead of IM for administering pain medications.
8. Prevent, anticipate,
icipate, and institute aggressive treatment for pain before, during,
and after all painful diagnostic and/or therapeutic procedures.
9. Pain management resources include Pharmacy, MD's, CNS.
10. Anticipate and manage opioid-induced side effects. For patients on PCA or
epidural utilize pre-printed orders for side effect management. For other patients,
on opioid therapy, utilize a stool softener/laxative combination (e.g. Senokot-S) to
prevent constipation, antiemetic [e.g., Ondansetron (Zofran)] for nausea/vomiting
and an antihistamine [e.g., diphenhydramine (Benadryl)] for itching.
11. Offer non-pharmacologic interventions. During painful procedures for infants,
encourage breastfeeding, holding, or offering 24% sucrose as appropriate.
a. Physical Agents:Heat/cold
Agents
Applications, massage, exercise, TENS,
immobilization, or re-positioning
b. Cognitive-Behavioral: Guided Imagery, relaxation techniques,
music/sound therapy, preparatory information, slow rhythmic breathing,
diversional activities (children)
c. Developmental Care for neonates/infants - Non-nutritive sucking,
Repositioning with boundaries, nesting, swaddling, and positioning aides,
Holding and rocking as appropriate, skin-to-skin contact, decreased
noise, light and tactile stimulation
d. Distraction/Relaxation: for pediatrics—age appropriate distraction (toy,
game or movie). Age appropriate relaxation techniques (parental touch,
soothing speech, breathing techniques, guided imagery).
C. Communicate the pain management plan on patient transfer to other nursing units or
services, as well as to other care facilities on patient discharge.
D. Provide discharge instructions regarding pain management including how to take
medications and what to report to the physician.
V.
PROCEDURE: PAIN MANAGEMENT – NEONATE/ PEDIATRIC
A. Definitions
1. Newborns and pediatrics (0-17 years of age)
2. Pain is an unpleasant sensory and emotional experience associated with actual
or potential tissue damage and effects of the environment. Infants/children who
are premature, ill, drug exposed or require surgery have the potential for pain.
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Policy and Procedure
Pain Management – Acute Pain
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3. Unrelieved pain is defined as:
a. N-PASS score of 4 or greater than which continues one hour after
intervention.
b. FLACC score of 4 or greater than which continues one hour after
intervention.
c. As defined in definitions on page one.
d. FACES scale of 4 or greater.
4. Pain relief is the alleviation of pain or a reduction of pain, decreased pain
responses and increased comfort and organized behaviors.
B. Standards of Care of Pain Management – Infants/Pediatric/Principles for Assessment
1. Assess for pain on admission including onset, physiological and behavioral
indicators, and aggravating factors, taking into account maternal factors and age
of patient.
2. Pain scores should be directly reported by the patient using Numeric, Verbal or
Faces scale. If the patient is unable to self-report FLACC, N-PASS or behavioral
indicators are used (e.g., N-PASS; FLACC for 0-7 years of age)
3. Routinely assess for pain at regular intervals completing it with vital signs and
physical assessments every shift (minimum of t.i.d., approximately every 8 hours)
or as directed by physician. Reassess after each pain management intervention,
within two hours (general guidelines are 30 minutes for IV interventions and 60
minutes for PO/IM and non-pharmacological interventions).
C. Principles of Intervention
1. All infants must be provided with non-pharmacological interventions to help
relieve pain as stated in the Protocol for Developmental Care:
a. Involve parents
b. Decrease noise and light.
c. Cover isolette
d. Speak softly to infant
e. Support with boundaries, nesting, positioning aides to promote a balance
of flexion and extension postures
f. Handle infant slowly and smoothly
g. Work around sleep/wake patterns and try not to interrupt sleep. Cluster
care.
h. Promote self-regulatory behavior - holding, grasping, sucking
2. Infants undergoing a procedure, with potential for pain, can benefit from Sucrose
24% as a pain management comfort measure. Examples of procedures; heel
stick, venipuncture, tape removal & dressing changes, suctioning, eye exam,
strenouous OT/ PT, circumcision, immunizations, and urinary catheterization.
a. Gather 24% sucrose solution and oral syringe or pacifier.
b. Administer the dose by dipping pacifier in solution or give by syringe into
side of mouth. The sucrose is absorbed via oral mucosa.
c. Sucrose and non-nutritive sucking induces endogenous opioids providing
analgesia for approximately two minutes.
d. Administer dose within a 2 minutes of pending procedure for efficacy.
(Maximum dose is 2ml= 8 doses in 24 hours.)
e. Giving sucrose may decrease cry duration, heart rate, facial grimacing
and lower ratings on neonatal pain scales.
f. Monitor pain throughout procedure (N-PASS), continue dosing through
procedure to maintain comfort, not to exceed maximum dose.
Maple Grove Hospital
Policy and Procedure
Pain Management – Acute Pain
Page 5 of 12
g. Provide other non-pharmacologic comfort measures in addition. Sucrose
is less effective in older infants 6-18 months of age.
h. Sucrose is contraindicated in infants with the following;
i. absent bowel sounds
ii. GI surgery in previous 5 days, active persistent pulmonary
hypertension
iii. presence of nectrotizing enterocolitis, or at risk for, feeding
intolerance
iv. asphyxiated infants
v. hyper-/ hypo- glycemia
vi. corrected gestational age less than 28 weeks
vii. poor perfusion
viii. receiving dopamine or dobutamine
3. Pediatric patients
a. Assess using age appropriate pain scale.
a. FLACC - 2 months to 7 years
b. FACES - As young as 3 years
c. Numeric - As young as 5 years
d. Behavioral - Over 7 years but unable to use other scale
b. Form trusting relationship with parent and involve them in
assessing pain.
c. Use age appropriate techniques to prepare the patient for pain.
d. Offer non-pharmacologic strategies
a. Age appropriate distraction (toy, game, talk, movie or other
interest).
b. Age appropriate relaxation techniques (parental touch,
soothing speech, breathing techniques, guided imagery).
VI.
CROSS REFERENCE
American Pain Society, (2003). Principles of analgesic use in the treatment of acute pain
and cancer pain, APS: Glenview, Illinois.
Feldt, K. (2000). The checklist of nonverbal pain indicators (CNPI). Pain Management
Nursing. 1(1), 13-21.
Herr, K., Bjoro, K. & Decker, S. (2006). Tools for assessment of pain in nonverbal older
adults with dementia: a state-of-the-science review. Journal of Pain and Symptom
Management. 31(2), 170-192.
Merkel, S.I., Voepel- Lewis, T., Shayevitz, J.R., Malviya, S. (1997) The FLACC: A
Behavioral Scale for Scoring Postoperative Pain in Young Children, Pediatric Nursing
23(3), 293-97
Puchal, M.G., Hummel, P. (2002). Neonatal Pain, Agitation & Sedation Scale. Retrieved
Feb 2009 from www.n-pass.com/tool.htm
VanHerk, R., VanDijk, M., Baar, F., Tibboel, D. & deWit, R. (2007). Observation scales for
pain assessment in older adults with cognitive impairments or communication difficulties.
Nursing Research 56(1), 34-43.
Anand, KJS. (2008) Analgesia for skin-breaking procedures in newborns and children: what
works best? CMAJ:JAMC, 179(1): 11-12.
Boyle, EM. Et.al. (2006) Sucrose and non-nutritive sucking for the relief of pain in screening
for retinopathy of prematurity: a randomized controlled trial. Arch.Dis. Child. Fetal
Neonatal Ed, 91: 166-168.
Maple Grove Hospital
Policy and Procedure
Pain Management – Acute Pain
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Codipietro, L., Ceccarelli, M. & Ponzone, A. (2008) Breastfeeding or oral sucrose solution in
term neonates receiving heel lance: a randomized, controlled trial
Pediatrics, 122: e716-e721.
Golianu, B. et.al. (2007) Non-pharmacological techniques for pain management in neonates.
Seminars in Perinatology, 31(5): 318-322.
Harrison, DM. (2008) Oral sucrose for pain management in infants: myths and
misconceptions. Journal of Neonatal Nursing 14: 39-46.
Leef, KH. (2006) Evidence-based review of oral sucrose administration to decrease the pain
response in newborn infants. Neonatal Network, 25(4): 275-284.
Merenstein, G. & Gardner, S. (2006) Handbook of neonatal intensive care (5th ed.) Pain and
Pain Relief Chapter 12, St. Louis: Mosby.
Shah,PS, Aliwalas LL, Shah V. (2008) Breastfeeding or breast milk for procedural pain in
neonates (review). The Cochrane Collaboration. Published by John Wiley & Sons, LTD:
1-32.
Taddio, A. et.al. (2008) Effectiveness of sucrose analgesia in newborns undergoing painful
medical procedures. CMAJ: JAMC, 170(1), 37-43.
Wong, DL., Hockenberry-Eaton, M. (2001) Wong’s Essentials of Pediatric Nursing. (684708).
VII.
ATTACHMENTS
Attachment A – Faces Pain Scale and Behavior Pain Scale
Attachment B – NPASS
Attachment C – FLACC Scale
Attachment D – Numeric Pain Scale
Maple Grove Hospital
Policy and Procedure
Pain Management – Acute Pain
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Attachment A – Faces Pain Scale and Behavior Pain Scale
Faces Pain Scale
Behavior Pain Scale
Describe how bad your pain is on a pain scale
to help your physician and nurse know if the
treatment is working or if a change is needed.
Rate your pain on a scale of 0 to 10.
(0 = no pain; 10 = worst possible pain)
Faces
Number
Directions: Use these five categories of behavior
descriptions to determine whether patient has pain,
but cannot communicate this verbally.
Breathing: Normal
 Occasional labored breathing.
 Short period of hyperventilation.
 Noisy labored breathing.
 Long period of hyperventilation.
 Cheyne-Stokes respirations.
Vocalization: None


Occasional moan or groan.
Low level speech with a negative or disapproving
quality.
 Repeated troubled calling out.
 Loud moaning or groaning.
 Crying.
 Sighs, grunts, gasps.
 “Ouch, that hurts.”
 Cussing during movement.
 Exclamation of protest “Stop!”
Facial Expression: Smiling or inexpressive
 Sad
 Frightened
 Frown
 Clenched teeth.
 Tightened lips.
 Distorted expressions.
Body Language: Relaxed






Tense.
Distressed pacing.
Fidgeting.
Rubbing affected area.
Rigid.
Fists clenched or clutching or holding onto
siderails.
 Knees pulled up.
 Pulling or pushing away.
 Striking out.
 Rocking.
 Constant hand motions.
Consolability: No need to console.


Distracted or reassured by voice or touch.
Unable to console, distract or reassure.
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Policy and Procedure
Pain Management – Acute Pain
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Attachment B - N-PASS
Assessment
Criteria
Sedation
-2
Crying
No cry with
painful stimuli
Irritability
Behavior
State
No arousal to
any stimuli
No spontaneous
movement
Facial
Expression
Mouth is lax
No expression
Extremities
Tone
Vital Signs
HR, RR, BP
SaO2
No grasp reflex
Normal
-1
Moans or cries
minimally with
painful stimuli
Arouses
minimally to
stimuli
0
1
Irritable or crying at
intervals
High-pitched or silentcontinuous cry
Not irritable
Consolable
Inconsolable
Appropriate for
gestational age
Restless, squirming
Arching, kicking
Awakens frequently
Constantly awake or
arouses minimally / no
movement (not
sedated)
Any pain expression
intermittent
Any pain expression
continual
Intermittent clenched
toes, fists or finger
splay
Continual clenched
toes, fists or finger
splay
Body is not tense
Body is tense
 10-20% from
baseline
 > 20% from baseline
Little
spontaneous
movement
Minimal
expression with
stimuli
Relaxed
Weak grasp
reflex
Relaxed hands
and feet
 muscle tone
Normal tone
< 10% variability
from baseline
with stimuli
2
Appropriate
crying
Appropriate
Flaccid tone
No variability
with stimuli
Pain / Agitation
Within baseline
or normal for
gestational age
Hypoventilation
or apnea
SaO2 76-85% with
stimulation - quick 
SaO2 < 75% with
stimulation - slow 
Out of sync with vent
© Hummel & Puchalski (Rev. 8/14/01)
Pat Hummel, MA, RNC, NNP, PNP & Mary Puchalski, MS,
RNC
Adapted from Loyola University Health System, Loyola
University Chicago, 2000
+ 3 if < 28 weeks gestation/corrected
age
+ 2 if 28-31 weeks
gestation/corrected age
+ 1 if 32-35 weeks
gestation/corrected age
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Policy and Procedure
Pain Management – Acute Pain
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Assessment of Sedation
Assessment of Pain/Agitation
 Sedation is scored in addition to pain for each
behavioral and physiological criteria to assess
the infant's response to stimuli
 Pain is scored from 0  +2 for each
behavioral and physiological criteria, then
summed
 Sedation does not need to be
assessed/scored with every pain
assessment/sore
 Sedation is scored from 0  -2 for each
behavioral and physiological criteria, then
summed and noted as a negative score (0 10)
 A score of 0 is given if the infant's response
to stimuli is normal for their gestational age
 Desired levels of sedation vary according to
the situation
 Points are added to the premature
infant's pain score based on their
gestational age to compensate for their
limited ability to behaviorally or
physiologically communicate pain
 Total pain score is documented as a
positive number (0  +10)
 Treatment/interventions are indicated for
scores > 3
 Interventions for known pain/painful stimuli
are indicated before the score reaches 3
 "Deep sedation"  score of -10 to -5 as
goal
 The goal of pain treatment/intervention is a
score <3
 "Light sedation"  score of -5 to 2- as goal
 More frequent pain assessment indications:
 Deep sedation is not recommended unless
an infant is receiving ventilatory support,
related to the high potential for apnea and
hyperventilation
 Indwelling tubes or lines which may
cause pain, especially with movement
(e.g., chest tubes)  at least every 2-4
hours
 A negative score without the administration of
opioids/sedatives may indicate:
 The premature infant's response to
prolonged or persistent pain/stress
 Receiving analgesics and/or sedatives 
at least every 2-4 hours
 30-60 minutes after an analgesic is given
for pain
 Neurologic depression, sepsis, or other
pathology
Pavulon/Paralysis
 It is impossible to behaviorally evaluate a paralyzed infant for pain
 Increases in heart rate and blood pressure may be the only indicator of a need for more
analgesia
 Analgesics should be administered continuously by drip or around-the-clock dosing
 Higher, more frequent doses may be required if the infant is post-op, has a chest tube, or
other pathology (such as NEC) that would normally cause pain
 Opioid doses should be increased by 10% every 3-5 days as tolerance will occur without
symptoms of inadequate pain relief
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Policy and Procedure
Pain Management – Acute Pain
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Policy and Procedure
Pain Management – Acute Pain
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Attachment C – FLACC Scale
FLACC SCALE
(FACE, LEGS, ACTIVITY, CRY, CONSOLABILITY)
0
1
FACE
No particular
expression or smile
Occasional grimace
or frown, withdrawn,
disinterested
1
Frequent to constant
frown, clenched jaw,
quivering chin
2
Normal position
Or
relaxes
Uneasy,
Restless, Tense
Kicking
Or
Legs drawn up
0
1
2
Lying quietly
Normal position
Moves easily
Squirming
Shifting back/forth
Tense
Arched
Rigid
Or
Jerking
0
1
2
No cry
Moans or whimpers
Occasional Complaint
Crying Steadily
Screams or Sobs
Frequent Complaints
0
1
2
Content
Relaxed
Reassured by
occasional touching,
hugging, or "talking
to"
Distractable
Difficult to console or
comfort
0
LEGS
ACTIVITY
CRY
(Awake or Asleep)
CONSOLABILITY
2
The FLACC is a behavior pain assessment for use in non-verbal patients unable to provide
reports of pain.
Instructions:
1. Rate patient in each of the five measurement categories
2. Add together
3. Document total pain score
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Policy and Procedure
Pain Management – Acute Pain
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Attachment D - Numeric Pain Scale




Description
o Our numeric scale is vertical
because many people find a
vertical scale more intuitive.
Scoring
o Maple Grove protocol states that
treatment/interventions should
be initiated for pain intensity
rated higher than 4, or outside
the patient’s stated comfort goal.
o Patients with chronic conditions
or high pain tolerance may score
their pain in 1-3 range and it is
their target comfort range.
Target Population
o This scale is not appropriate for
patients who have diminished
mental capacity, or children.
o The scale is not recommended
for deaf patients by itself. The
scale should be put into context
using American Sign Language,
or written English.
Strengths and Limitations
o Strengths: Most commonly used
pain scale in healthcare
o Limitations: Patients may have
difficulty with the concept of 10
representing “the worst pain you
can imagine.”
o Instead, before assessing pain,
ask your patient to describe the
worst pain they have previously
experienced and refer to their
prior pain experience as a “10”.
o Using their prior pain as a
reference, ask the patient to
compare their current pain to it.
o Keep in mind that their current
pain may become the new “10”.
Numeric Pain Scale 10‐ Worst Pain 9 8 7 6 5 4‐ pain outside of comfort goal without treatment/ intervention 3 2 1 0‐ No Pain